I may post more information about the meeting later, but the general tone of the MAC medical directors was confident.
Blog Posts by Caroline Fife, MD
CGS Chief Medical Officer is Hosting a Meeting on the New Cellular Tissue Product / Skin Substitute LCD on December 20th
CGS J15 Webinar on Skin Substitute Grafts/Cellular and Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers
AMA sues MultiPlan Alleging Price-Fixing for Out-of-Network Physician Payments
The American Medical Association (AMA) and the Illinois State Medical Society (ISMS) have filed a lawsuit in federal court.
CMS Releases the Medicare Physician Fee Schedule Final Rule for 2025
The sad news is that CMS is going ahead with a 2.9% cut to Medicare physician reimbursements for 2025.
CMS Releases 2025 Final Rule for the Hospital Outpatient Prospective Payment System (OPPS)
The short version, based on my cursory read, is that no old problems were fixed but no new problems were created by the final rule.
Breaking News! LCDs for Cellular Tissue Products / Skin Substitutes Released!
LCD – Skin Substitute Grafts/Cellular and Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers (L39756)
Bipartisan Bill Introduced That Would Provide a 4.7% Medicare Physician Payment Update
It would eliminate the 2.8% Medicare physician payment cut and provide a positive update that equals half of the Medicare Economic Index.
FDA Approves Changing the Expiration Date of Some IV Fluids Made by Baxter to Help Alleviate Shortages
Baxter International is one of the largest suppliers of IV fluids in the United States with its North Cove facility providing 60% of IV fluid in the USA.
Check Your Final 2023 MIPS Scores Available Online – Scores Will Impact 2025 Physician Payment!
Should an error be found, the deadline to request a review is Oct. 11 at 7 pm CT.
“To Self-Disclose or Not to Self-Disclose”: Check Out Attorney Knicole Emanuel’s Blog
Self-disclosure is better than waiting to get caught. Lives can be ruined if you wait to get caught.
Templated Notes and Medicare Audits
If practitioners encounter denials by auditors based on the use of note templates, they should probably seek legal counsel.
Loss of Baxter Facility in N.C. from Helene is Affecting Availability of IV Solution and Shortages May Worsen Due to Hurricane Milton
Hospitals are facing shortages of IV fluids following Hurricane Helene’s damage to Baxter International’s North Cove manufacturing site in Marion, N.C.
Reminder: Final Scores for the 2023 Performance Year of Medicare’s Merit-Based Incentive Payment System (MIPS) are Now Available Online and the Deadline to Request a Review is October 11 at 8 PM ET
Check your scores soon as they will impact your 2025 Medicare payment!
UnitedHealthcare Launches a “Gold Card” Program in October to (Hopefully) Reduce Prior Authorization Woes
The program will be offered across its commercial, individual exchange, Medicare Advantage and Medicaid business lines.
Due to the Impact of Beryl, CMS Has Automatically Applied a Hardship Exemption Within the 2024 Merit-Based Incentive Payment System (MIPS) Performance Period to Eligible cC Areas
The extreme and uncontrollable circumstances (EUC) policy will apply in affected Texas counties as identified by federal public health emergency and disaster declarations.
Check Out the New Article in TWC “I’m Getting Audited – Now What?” by Stephen Bittinger
Mr. Bittinger’s article explains the various types of audits, what’s at stake, and how an attorney might help.
Aetna to Cut Payment for Urgent Care Surgical Services and Payments for NPs and PAs
Wound Care practitioners who bill site of service 49 (independent clinic) take note!
The Average Cyberattack Breach Costs ~$11 Million – and the Number of Attacks Per Week is Increasing
Ransomware attacks have dominated, accounting for over 70% of successful cyberattacks on healthcare organizations in the past two years.
In 2025, Physicians Face a 2.8% Pay Cut While Mandatory Participation in an MVP Looms
In 2024, physicians had a 1.68% pay cut and they remain the only Medicare providers to not receive an inflationary update.
Does Which EHR a Doctor Uses Impact the “Cost” Category of MIPS?
Wound care practitioners have higher TPCC costs when compared to their peers. To CMS, they look like they spend too much money.
Noridian and CGS Release FAQs on Lymphedema Compression Treatment Items
Noridian and CGS Provider Outreach and Education have released the most frequently asked questions (FAQs) on lymphedema compression treatment items under the Lymphedema Treatment Act.
Health Information Technology Proposed Rule (HTI-2) is Out
ONC will be hosting information sessions in the coming weeks, including an overview session on July 17 at 2:00 PM ET.
Global Internet Outage Continues to Impact Many Healthcare Systems
Human error may be just as much of a risk as hacking, ransomware and other intentionally malicious assaults.
2025 Medicare Physician Fee Schedule is Out (and CMS Did Not “Package Price” Cellular Tissue Products / Skin Substitutes in the Doctor’s Office)
The billing of CTPs in the doctor’s office is unchanged. The 2025 Medicare conversion factor is set to decrease for the fifth straight year.
Breaking News! OPPS Proposed Rule is Out!
At first glance, there are no changes to Cellular Tissue Product /skin substitute payment, which remain under package pricing in this site of care.
Accelerated and Advance Payment (AAP) for Medicare Ends on July 12
CMS announced that Medicare payments under the Accelerated and Advance Payment (AAP) Program for the Change Healthcare/Optum Payment Disruption (CHOPD) will end on July 12.
CMS Adds 76 New Items to its Master List of DME Supplies That May Be Subject to Prior Authorization (and Some Surgical Dressings are on the List)
The Centers for Medicare & Medicaid Services (CMS) added 76 new items and deleted three from its master list of durable medical equipment (DME), prosthetics, orthotics, and supplies.
How the DEA is Working to Help Communities Get Rid of Unused or Expired Prescription Medications
You can find a medication collection site by putting in your zip code on the Collection Site Locator.
How to Subscribe to the NGS Self Service Plus Newsletter
If NGS is your MAC, you might want to subscribe to the Self-Service Plus newsletter, accessed online.
Physicians Have Until Dec. 31 to File a MIPS Hardship Exemption Due to the Change Cyberattack
The 2024 MIPS EUC portal is now open, and physicians have until Dec. 31 to file a hardship application and avoid a 2026 MIPS negative payment adjustment.
What Doctors Wish Patients Knew About Prior Authorization
Maybe if I’d let patients read this article, I could have discussed the issue with my patients honestly, rather than just running away from it.
Pneumatic Compression Devices Are in the Spotlight for 2024 Audits
Check out the article by Knicole Emanuel in Today’s Wound Clinic: Pneumatic Compression Devices Are in the Spotlight for 2024 Audits.
CMS Explains its 2024 Value-Based Care Strategy
CMS ALWAYS tell us what they are going to do before they do it. Then they do it, and we are surprised.
A Little Reprieve for Physician Pay Cuts
A 3.4% Medicare physician pay cut took effect on January 1, 2024. However, thanks to the passage...
CMS Announces Flexibilities in the Wake of the Change Cyberattack
CMS is encouraging MA plans to offer advance funding to health care professionals most affected by the cyberattack.
CMS Announces Reopening of 2023 MIPS EUC Application in Response to Change Healthcare Cyberattack
I am reposting the entire message from the CMS about the extension of the Extreme and Unavoidable...
CMS Removes the Requirement for AUC From the 2024 Medicare Physician Fee Schedule
Implementing the AUC program would have been a time consuming and expensive lift for practitioners.
Update on the Surgical Dressing Policy – Thanks to the Alliance of Wound Care Stakeholders
The Alliance of Wound Care Stakeholders has had another policy win!
Resources from CMS and the AMA to Help You Implement Changes to Physician Documentation & Billing
There have been two major changes in the regulations pertaining to physician documentation during ambulatory visits, both of which are favorable for wound care practitioners.
Medicare Audits on Pneumatic Compression & Surgical Dressings – “It’s About the Documentation…”
I am a huge fan of attorney Knicole Emanuel’s blog and her most recent post is directly relevant to the field of wound care.
Be Careful Billing the New CMS G2211 Add-on Code for Visit Complexity
It is intended to “better recognize the resource costs associated with evaluation and management visits for primary care and longitudinal care.”
Claims Disruptions Continue After Cyberattack on Change Healthcare
This is yet another blow to hospitals and physicians that are struggling to make ends meet in the face of payment reductions.
Ransomeware Cyberattack on Change Healthcare is Affecting Individual Physician Practices Too
United Health-owned Change Healthcare has confirmed the ransomware group “ALPHV/Blackcat” is...
CMS Final Rule on Prior Authorization Released
Prior authorization (PA) is costly, inefficient and responsible for patient care delays. The...
Surgical Dressing Webinar by Noridian on March 7th
On Thursday, Mar 7, 2024 from 12:00 PM – 1:00 PM CST, Noridian is offering a webinar on Surgical Dressings. It is intended for DME suppliers.
Noridian Offering Tutorials on Hyperbaric Oxygen Therapy (HBOT)
Noridian is offering two self-paced training tutorials to “assist providers and facilities in better understanding Hyperbaric Oxygen (HBO) Therapy.”
Novitas Releases Top Ten Reasons for Claims Denials…and Wound Centers Should Especially Check Out Reason #7
Reason #7 for claim denials is especially relevant to hospital-based outpatient wound centers (HOPDs).
Noridian is Offering a Feb 13th Webinar on the Lymphedema Compression Benefit Category
On February 13th, 2024, Noridian is offering a Webinar for DME suppliers about lymphedema compression benefits.
Pneumatic Compression Devices Webinar by Noridian on Feb 13th, 2024
On Tuesday, Feb 13, 2024 from 2:00 PM – 3:00 PM CST, Noridian is offering a webinar intended for DME suppliers about pneumatic compression devices (PCDs).
The Deadline to Submit MIPS Data for 2023 is April 1 at 6 pm EST to Avoid up to a 9% Penalty on Medicare Revenue
The data submission period for Medicare’s Merit-Based Incentive Payment System (MIPS) 2023 performance year is underway.
Time Sensitive! It’s Not Too Late to Sign the Letter to CMS Protesting the 41.5% Reduction of HBOT Facility Fees!
I know the holidays are busy – but most of us would like to have a job to go back to in January…
Without Warning – the Outpatient Prospective Payment Final Rule Cuts HBOT Facility Fees by 40%
What we need is for people to submit a comment, and to spread the word that hyperbaric oxygen therapy is in a crisis.
Modifications Needed to Wound Center EHR to Support DME Orders for Dressings
Your EHR will need to be modified to meet the DME documentation requirement burden (and if you think the list below is ridiculous – it is, but it’s still required).
Mindfulness, Electronic Health Records and Ebola
A recent Ebola outbreak in Dallas was blamed on a “flaw” in the hospital’s electronic health record (EHR). Yes, you heard me correctly.
Observations About the 2024 PFS Pertaining to Cellular and/or Tissue-Based Products in the Doctor’s Office Setting
On July 13, 2023, CMS issued proposed rules for the 2024 Physician Fee Schedule (PFS) and the Hospital Outpatient Prospective Payment System (OPPS).
“Hidden RAC Audits” – Seriously…
Attorney Knicole Emanuel has posted a chilling blog on her site about hidden RAC (Recovery Audit Contractor) audits.
Listen to a Podcast with Dr. Helen Gelly, “How to Get Your Wound Clinic Through an Audit”
On your drive home, check out this podcast with Helen Gelly MD, FUHM, FACCWS, UHM/ABPM, “How to Get Your Wound Clinic Through an Audit.”
HBOT Facility Payments are Under Attack (Physician Supervision is Next…)
We need individuals at all training levels to comment on the proposed changes that CMS is proposing in the Medicare Physician Fee Schedule (MPFS) for the technical payment of HBOT.
Check Out the Long List of CTPs (“Skin Subs”) Not Covered in the CGS, First Coast, & Novitas LCDs
Three Medicare Administrative Contractors (MACs) issued their final Local Coverage Determinations (LCDs) for Cellular and/or tissue-based products (CTPs).
Highlights of the 2024 Outpatient Prospective Payment System (OPPS)
You should read the documents yourself, but here are some highlights of the 2024 OPPS proposed rule (in no particular order).
PRESS RELEASE: New Study in Journal of Medical Economics Shows Decrease in Chronic Wound Medicare Costs Amid Increase in Chronic Wound Prevalence
Over 2014-2019, the number of Medicare beneficiaries with chronic wounds increased 13% to 10.5 million amid a surprising 20% reduction in chronic wound expenditures. Researchers seek to explain why, and what the policy implications may be.
Chiropractors Treating Diabetic Foot Ulcers?
I am highly suspicious that this is being driven by the manufacturers of CTPs, and is yet another indication that the CTP industry is out of control.
Prior Authorization Nightmares & the Antidote to Burnout
Here’s a doctor who knows his days are numbered, and he’s making the most of every one because he has a purpose.
HIPAA Does NOT Require That Healthcare Providers Obtain Patient Authorization to Disclose Protected Health Information (PHI) to Other Clinicians for Treatment Purposes
HIPAA does NOT require that health care providers obtain patient authorization to disclose protected health information (PHI) to other clinicians for treatment purposes.
Medicare Extrapolation Under 50% Error Rate? No Extrapolation ALLOWED!
In Knicole Emanuel’s latest blog, she discusses the new Medicare rules stating that no extrapolation may be run if the error rate is under 50%.
The Quality Payment Program and What it Means for the Future of Wound Management & HBOT
The Big Picture of Physician Payment Within CMS The big picture is still playing out for physician...
The Lymphedema Treatment Act Passed!
The LTA will improve insurance coverage for the medically necessary, doctor-prescribed compression supplies that are the cornerstone of lymphedema treatment.
Medicare Posts Final Rule for 2024 Policy Changes to Medicare Advantage Plans – Review of Medical Necessity Requirements
Undersea and Hyperbaric Medicine IS a recognized medical subspecialty so that might help patients obtain necessary HBOT treatments.
Medicare Posts Final Rule for 2024 Policy Changes to Medicare Advantage Plans
The rule goes into effect Jan 1, 2024. Whether this will make MA less of a Medicare DIS-advantage is yet to be seen.
CMS Published 2023 Medicare/caid Health Care Providers’ Audit Process – Read Attorney Knicole Emanuel’s Offer to Clinicians Being Audited
Nearly every wound care and hyperbaric medicine practitioner is undergoing some sort of Medicare audit.
Wound Care Services and the Jimmo Settlement – Why it Matters to Patients Who Are in Palliative Wound Care
Unfortunately, some Medicare auditors are not following the law as it pertains to the presence or absence of a beneficiary’s potential for improvement.
Are Verbal Orders Prohibited?
There are no federal regulatory prohibitions on the use of verbal orders, although CMS frowns upon verbal orders in the context of medications.
Give Yourself the Gift of an Audit
A self-audit is a miserable “gift” to give yourself, but a real audit is a gift that just keeps on giving when you are not prepared.
Debunking Myths About Who Can Enter Information Into the Patients’ Medical Record
In its effort to debunk regulatory myths, the American Medical Association (AMA) has produced this useful fact sheet, “Who can document components of E/M services?”
Check Out the AMA Summary of the 2021 Rules for Billing E/M Visits by Time
The AMA reminds physicians that that there is no requirement to document the total time spent if the physician is not using time to calculate the level of service.
The AMA Debunks Myths Around Clinical Support Staff Documentation Inside EHRs
The American Medical Association (AMA) has been debunking several myths in a project called “Debunking Regulatory Myths.”
Reminder: 10 Days Until the Close of the 2022 MIPS Data Submission Period
The Centers for Medicare & Medicaid Services (CMS) has opened the data submission period for Merit-based Incentive Payment System (MIPS) eligible clinicians who participated in the 2022 performance year of the Quality Payment Program (QPP).
District Court Upholds ALJ’s Decision That Extrapolation Was Conducted in Error
A new post by attorney Knicole Emanual is vitally important for anyone under a Medicare audit.
Check Out This Article by Kathleen Schaum in Today’s Wound Clinic
Check out this article by Kathleen Schaum in Today’s Wound Clinic: Are You Prepared to Implement the 2023 CTP Final Rules?
Pandemic Emergency Declarations Scheduled to End May 11, 2023 – Check Out These CMS Resources
On January 30, 2023, the Biden-Harris Administration announced its intent to end the national emergency and public health emergency (PHE) declarations related to the COVID-19 pandemic on May 11, 2023.
Join the Fight with the Alliance of Wound Care Stakeholders
Are you feeling frustrated and helpless in the face of overwhelming regulatory burdens, capricious...
Check Out This Post: The Ugly Truth about Medicare Provider Appeals
The way these audits work, it’s assumed you are guilty and you have to prove you are not – in a one way conversation.
Documentation Requirements for Wound Care Services – Part 3
Not only do you need to document the goals of therapy, but you need to document whether your treatments are achieving them.
Documentation Requirements for Wound Care Services – Part 2
Healing does not have to be the goal, but if not, we had better state goals like, “getting the wound to a state in which the patient and family can care for it with only periodic physician assessment,” or “preventing progression and hospitalization.”
Documentation Requirements for Wound Care Services – Part 1
I am going to discuss the wound care policy that’s been in effect since 07/23/2020 for the Novitas jurisdiction.
CMS and CTPs (Cellular Tissue Products)
The full attention of every aspect of CMS is now focused on the use of CTPs. Why do you think that is?
The 2023 Medicare Physician Fee Schedule Proposed Rule is Out
Sweeping changes are proposed for cellular and/or tissue-based products (CTPs) when applied in the physician’s office.
RAC Provider Audits and Why You Need to Worry
If you want to know what topics the Centers for Medicare and Medicaid Services (CMS) are auditing,...
Homework from Audit Session One
Kathleen Schaum provided the first of 4 free sessions on "Keeping your Payment after an Audit."...
The Devil in the Documentation Details of the Proposed Novitas LCD on “Skin Substitutes” – Part 5
In case you think you are safe because you live in another MAC jurisdiction, it’s the same as the First Coast policy and it won’t surprise me to see all the MACs adopt the same (flawed) policies.
The Devil in the Documentation Details of the Proposed Novitas LCD on “Skin Substitutes” – Part 4
This is Part 4 of the list of what you need to document (per the proposed rule) if you want to use a skin substitute (CTP) for a DFU or VLU.
The Devil in the Documentation Details of the Proposed Novitas LCD on “Skin Substitutes” – Part 3
Novitas is going to limit clinicians to 2 applications of a “specific skin substitute” over the 12-week period defined by the date of the first application.
The Devil in the Documentation Details of the Proposed Novitas LCD on “Skin Substitutes” – Part 2
I am not even halfway through the details of the proposed policy, so stay tuned for more.
The Devil in the Documentation Details of the Proposed Novitas LCD on “Skin Substitutes” – Part 1
If you want to present comments on any of the proposed policies in the Novitas LCD, sign up to attend the Open Meeting.
The Department of Justice and the Drug Enforcement Agency Announce New Searchable Portals for “Guidance Documents”
This portal contains a single, searchable, indexed database that contains links to all DEA guidance documents.
A Simple Nutritional Algorithm for Patients with Chronic Wounds
I will be the first to admit that I did a bad job recognizing and treating nutritional deficits in...
CMS Rulings Are Not Law; Yet Followed By ALJs
As wound care begins to shift into the private doctor’s office – doctors are not going to be able to just may paybacks without a fight.
You said it Knicole! Stop Auditing Practitioners and Start Auditing Medicare Advantage Plans!
“Maybe it’s time to switch our telescopic lens from auditing providers to auditing MCOs and MAs. Let’s get these RAC, ZPIC, and TPE auditors focused on the stewards of our tax dollars, the prepaid entities.”
Documenting “Wulcers”
Wound care terminology & diagnosis codes haven’t changed since 1991, but wound care technology definitely has.
Take a Firsthand Look at a TPE (Targeted Probe & Educate) Audit
Dr. David Charash has just put out an article in Today’s Wound Clinic describing his experience with a TPE (Targeted Prove and Educate) audit. Check it out!
Caroline Fife, MD
Dr. Fife is Co-Founder and Chief Medical Officer of Intellicure, Executive Director of the US Wound Registry, and Editor of Today’s Wound Clinic.